Surf, Turf and Veins

I know it's been a while, I know. I don't feel like it so much, but it must be that I have less free time on this rotation than I did on the last. That being the case, my ramblings have been fewer and lower in quality and length.

don't judge me.

Let's bring you up to speed...

On the slave labor front, I've been in Cardiothoracic Surgery for 3 and a half weeks now, and love it. I'm still getting to do more and more everyday. I had no grand illusions that I would be doing too much during the actual surgery, I mean, it's heart surgery!

I knew I wouldn't be doing much more than watching and helping close at the end, if I was lucky. And I knew for certain that I wouldn't be harvesting the Great Saphenous vein for the graft conduits....

but then again, I've been doing much more than expected these past few weeks. After I finished helping Dr. Gately open, I switched sides to watch Alec take the saphenous vein. He was midway through, about at the point where he'd switch tips on the scope so he can cauterize any side-chains of the vein, and then extract it from the leg...

It was right then, in a moment of silence (save for the music playing in the background) that was shattered by Alec's voice, "Here, you do this. I'm bored." As he hands me the scope.

YES!

He wasn't bored, he was just being nice, giving me an opportunity to become familiar with the equipment. In the process, he made my day.

It came easy to me, it's like playing a video game. Just watch the screen, and react with your hands. It's like the medical nerd's version of Nintendo Wii. And we nerds happen to think it's much more fun.

So, in a nutshell, that's work lately.

On the extended work front, they let me attend a free (St. Jude Medical sponsored) dinner last night, (with a 'pro St. Jude prosthetic valve' lecture, of course.)

WORTH IT.

"I could get used to this." I thought while watching my free Fillet Mignon arrive to the table, preceded by appetizers, a salad, and followed by a wonderful dessert; homemade cheesecake and a chocolate ganash.

Apparently, El Gaucho is the most expensive steak house in the city. I can't tell you if this is true for certain, but the food sure made a case for that argument, as did the service. As soon as I walked into our private room, a man in a tuxedo asked if I'd like something to drink.

"Why yes I would, how about an IPA..."

It was a good evening.

Though I seem to be more busy this rotation, I did carve out time for fun this past weekend. I went surfing with my roommate, Ryan, near Canon beach on Saturday. It was a beautiful day at the coast, at least where we were. It was my first time surfing, and I did manage to catch quite a few waves. I'm hooked.

The only problem is that I must have zipped up my wetsuit with a kink in the neck somewhere, because it managed to rub off a good part of my skin on the back right side of my neck. It looks ridiculous, and kind of hurts still.

I hope it heals up enough by Saturday, cuz I'd love to go again.

That night I met up with a Minneapolis friend who was in town, and got to spend the next day with her too. Had a great time...

I guess that's all for now folks... I'm in need of food, and I think my chicken has got to be thawed by now.

Sorry for the lack of insight, wit, humor and life lesson... but I'm fresh outta those right now. Maybe later.

cn

it's just not in the air

It's awfully nice out today, or terribly nice out. Neither adjective seems to quite make sense when paired with 'nice' if you think about it. Terribly nice? Terrible? Well, who cares.... I guess I do, since I'm writing about it.

Anywho, it's fantastically nice out, and I'd very much like to be playing some badmitten in the backyard, or throwing a frisbee around in the park. But, as it turns out, we're all too busy to partake in these types of afternoon adventures. Instead our adventures consist of staring out the window from time to time while reading about all the things that we didn't quite grasp during the 'work day'.... or the 'getting WORKED day.'

At least I have some nice scenery to gaze at.

AND

At least I'm still really diggin' my rotation. I could really see myself working here. It's totally radical.

But, man, I really wanna work on my frisbee toss... or my golf swing.

maybe this weekend.

chasing the wind with suture

i like CT surgery.

i like the people there.

I like that they're letting me do things.

I like that the things get to be more and more each day.

I like that I'm learning copious amounts of information, in and out of surgery.

I like that Dr. Swanson made a comment about something I don't remember, but it went something like this...

"It's like suturing farts to moonbeams."

I like it all.

attack! heart...

it's a sabbatical of sorts that I've been on... for the first two weeks of August anyway.

The first week was spent on a midwest tour with friends and family, which was jam-packed full of fun.... and went by too quickly. The second was spent with my classmates here in Portland, and too, went far too quickly. Both were quite enjoyable.

In stark contrast, for the past week i feel as if I'm living in the hospital. I suppose, for me, there would be worse places to live. Unlike most people, (normal people), I like the hospital. I don't mean that I enjoy being in one myself, sick or injured, or visiting a loved one... but for a place to work... it's great.

I love a big hospital, one you can get lost in.... it's simply wonderful. Cafeterias are open practically all night, the crew that is up late with the cafeterias is even more cool than getting a burger at 4 AM. and the nurses.... OOOOOOOOO.... beautiful. Is it a requirement? I'm not sure... but I approve.

The big hospitals are always so new, clean and modern. You can walk around just about anywhere when you're wearing scrubs and a white coat.... it's amazing. You'd be surprised at the areas that you can get into by just dressing and acting the part. I guess it's kind of scary. I think though, it's just the white coat that affords me such range in the hospital.... Nurses thell me things about their patients as if I'm some sort of authority. I'm not.

It's great.

well... whatever the reason is, I like my new domain. I feel at home.

So it was in this domain that I've been roaming the past 4 days. Doing rounds at 6 AM until 7... then in Surgery from 7 until around 5 PM, then more rounds until about 6 or 7.... I'm getting the hang of things now, in and out of the surgical suite. And so far, people have been great. The PA I've been working with is a smart guy, and a good teacher. The Surgeon is appoachable, friendly and sarcastic. And best yet, he's a Packer fan. He was born and rasied in Madison Wisconsin, where I just so hppened to go toundergrad. (it's nice to have something in common with your preceptor.)

So, everyone there has been in good spirits the past week, despite being awfully busy... jokes are constantly being cracked during surgery, even by the surgeon. I suppose a happy, even relaxed work environment is a good one, even if you are operating on someone's heart. Though, the juxtaposition of the gravity of heart surgery with the levity of off color humor, that comes as easily as at your favorite bar's happy hour, well.... it's interesting. I don't know how to describe the scene, and the feeling that accompanies it. To the person who is not in the medical profession, it may seem crass, but it's not. Maybe it's how we distance ourselves, maybe it's just a different breed of people who end up in surgical gowns for a living, or maybe it goes to show that no matter what carreer you create for yourself (even one as consequential as heart surgery)... there will always be room for dirty jokes, to break the silence and repition of the day to day routine. Because even with heart surgery, there is routine, there is boredom, there is repitition and there is a need for a laugh.

It's odd that this type of silliness can occur during such a serious, delicate and life threatening surgery, but it does.

It was on day three where I, almost unwillingly.... or maybe, well.... my mouth was ahead of my mind when i jumped in neck first. For it could have been my neck that was on the line if my comment didn't fly with the surgeon.

I was assissting with an AVR (aortic valve replacement), and at one point there are about 36 sutures, or long strings being tied and thrown over the open chest cavity where they will wait to be cut by him upon finishing all the knots. So I was at one of three spots where these groups of ties would be flung. Somone will corral the tosses (which are usually dead on, the surgeon has done this hundreds of times, if not thousands) and then give them back to the doc when he is ready. So, just as he's about to toss the first suture my way, he asks...

"Did you play any sports, Chris?"

"Yeah..."

"What did you play?" he asks as he flings the first suture towards my open hand. It lands perfectly in my palm. I fold my thumb over the sterile white thread that would hold this man's new valve in place.

"Baseball and football," I reply.

He flings another thread at me, which misses my motionless hand.

"Well why didn't you catch that one?!?!" He shoots sarcastically.

'Mess with the newguy huh? Well two can play at that game sir! You may be a surgeon, and he's only a PA student, and this may only be his third day.... and, sure, you hardly know him, so maybe this will crash and burn... but I am Chris' BRAIN, and sometimes I work quickly (not often) but today, possibly to Chris' dismay... I will defend him! I will show you how witty I can BE! I won't take your Tom-Foolery lying down! If you wanna fling one my way, I'll toss one right back I'll just go ahead and bypass Chris' good sense here..... and take THIS!'

Now, I didn't hear this going on in my head, I didn't even think it.... All I heard was what came out.... and I remember thinking, mid sentence.... 'oooooooohhhhhh, maybe shouldn't have said that... hope it goes over well.'

............

"Well why didn't you catch that one?!?!" said the lifelong Packer fan.

"It was a classic Brett Favre underthrow!" I bite back, quickly (too quickly.)

It seemed like forever from when the first word left my lips, to the terrifying thought of the surgeon slicing my heart out in less than 4 strokes, to the burst of laughter that came from not only the surgeon, but the rest of the crew.

WHEW!

It didn't take forever, and the only akward silence was in my mind. In actuality, I think he liked the bantor, and realized I was just zinging him back for zinging me. It's all in good nature, and we all know it. At least, I knew it for sure after the Brett Favre comment.

Meanwhile, during the stand-up comedy going on, the patient's heart is completely stopped, as well as their lungs... Their chest is spread open about 8 inches, they're hypothermic, they have tubes going in and out of their heart, face, neck, wrist, and urethra, and the biggest artery in their body is sliced wide open. By all means, they shouldn't be alive... and they kind of aren't.

It's like a mullet in reverse.

All business down low, and a party up front. Strange.

anyway...... that's all for now, I'm tired, and I'm hungry, and I need to learn more about heart surgery.

see you all later rather than sooner, and this is something i regret.

cn

I must have done something right...

Today was a good day...

"Do you want to do your evaluation now?"

"Sure." I say kind of excitedly.

I'm sort of like Angela from 'The Office' in that I think I thrive on being judged. It's not something I'm proud of, but it's sort of true. I think it stems from the fact that I feel it necessary to continually prove my worthiness as a PA student because of my less than stellar Undergrad grades.

Let's just say I pulled down my class average.

So, from that point on, I worked hard to make sure that any judgement passed upon me, as a PA student, would be positive. And if it's not, then I deserve that too... and I can take it and make the necessary changes to become the best PA I can be.

So, Bring it on Kalauawa... bring it.

I guess it's unfair for me to say that I had worry running through my mind, he had already said that he'd given me a good review, and I was one of the best students to come through the joint. (wow... I've got him fooled!) And I must say, that made my day.... REALLY made my day.

don't let it go to your head, dummy. you still have it in your amazing screw-up power to SCREW IT UP.

So I followed him down the hall to his office. I have a seat in an old wooden chair. It matches the rest of the clinic perfectly, in that it appears old, worn and unimpressive. But once I get into it, once I give it the smallest chance, I love it. It's as comfortable as any office chair I've ever sat in. It exceeds expectations.

Before I can even get a word out....

"Off the record, I think all this stuff going on between the Vikings, the Packers and Favre is crazy. They're all talking to eachother... I think Favre will end up with the Vikings."

(He is a huge Vikings fan.)

This is NOT the first time we've talked football, and this conversation lasts a few minutes. When it's over, both agree that if Favre can't play in Green Bay (which we both think is the right thing to do) that we want him to play for Minnesota.

He then, sans segway... save maybe a little sigh fading from the tail end of a laugh, shows me my ratings.... all above average, except for one, which is average. He tells me this is the best rating he thinks he's ever given. He gives an 'average' rating if you are where he expects for you to be, as a competent student.

Now, at my last rotation, I received all 'Superior' ratings... but that was kind of meaningless. They didn't put the time and effort into it that Dr. K did. I think they just liked me. Not that I did poorly, they told me that I did well, but I doubt that I was 'Superior' in all aspects of the rotation.

Whatever the case may have been then, after hearing Dr. Kalauawa's review of my performance, I'm flattered, happy, proud... and feel like a fraud - all at the same time. I think they're all valid things to be feeling at the time. This, I've decided after more than a few minutes to think on it.

But then came the whammy...

"So what I'm saying is that when you're looking for a job, if you want, you've got one here."

I'm speechless, really. They told us at school,before the shoved us outta the nest, that this might happen, and yet, I was not expecting it.... not at all.

"Wow, thank you! That REALLY means a lot to me."

As one of my old stand-by bands, Relient K, once said, "I must have done something right..."

Shoot....

it did occur to me that maybe he says the same dang thing to everyone who rolls through threre, but hey... it made my day none the less.

Now I just have to finish my flippin' geriatric mental health case study thing..........ughh. did the day just get worse?

a serious case of the spins...

Just a few things I'd like to mention to whoever might be reading this....

1. I made pasta tonight for dinner, and made a nice little white sauce to go with it. It ended up tasting pretty good, but my foot paid the price.

I feel like Michael Scott; I burned my foot in a cooking accident. Really.

I can't say I did it by stepping on a George Foreman grill, or that I'm wearing bubble wrap on it.... or best yet, that I tried to stick it in a CT scanner while a friend of mine was having his head checked out, but it happened. I was busy chopping garlic with that crazy Emeril chef guy... and before I knew it, my pan was HOT, and the olive oil was smoking... so I turned it down a bit, and realized I might need a BIT more olive oil. So I went to pour a bit more on there....

Well, I must have been going for a long distance pouring record, subconsciously... because the force that the oil built up on its seemingly endless fall to the screamingly hot pain was enough to send smoking hot oil flying from the pan, to the top of my unsuspecting left foot.

Poor left foot, he was just down there, minding his foot business... keeping me properly balanced on the floor... maybe he was even enjoying being naked... who knows! (I bet he was) Well, if he WAS, he must have quickly wished that he had been wearing his ol' buddy socks and shoes as soon as that soaring glob of pain found its way to the top of his bare skin.

I think I heard him call out in pain....

He's been bathing in ice for a while now.... and feeling better.

2. I watched a homeless guy spin circles in the park yesterday.

He would spin counter-clockwise for about 3 or 4 minutes, occasionally slowing down just a bit so he could take a drag off his cigarette, then he would start spinning clockwise for another 3 or 4 minutes.

His footwork was amazing.... and so was his whole ensemble.

He was wearing some fire engine red shorts, they looked like swim trunks, and were a little too short. He accompanied these with white socks up to mid calf and then some classic tennis shoes. He, of course, was shirtless. and this 60-something must have been in the midst of some massive beard-off with a friend or two of his... because this thing was amazing... almost as amazing as his equally long hair, which only paled in comparison to his spin moves.

Tony Hawk, watch out! A 1080 is child's play.

Once he was done spinning, he quickly started talking, to, well... nobody. but his hand gestures were grand, as if he were in some sort of terribly heated debate. They were swaying this way, and that. Up in the air, over his head as if appalled. Then he'd point with his right hand, still clasping cigarette, as if to accuse his adversary of some terrible deed.

I'd look to where his gaze and hand gestures were landing. I only saw birds.

Those birds must have really done something to deserve the tongue lashing that they were getting from this guy.

They didn't seem too scared.

3. DVT guy still has not gotten all his results back yet. We still don't know why he made a massive clot. Which brings me to my next point; I made my first house call the other day. I went to DVT guy's house and checked up on him, his leg, his heart and lungs. The clot did move up a bit, according to the second ultrasound, but it sure isn't in his lung. But his leg is awfully swollen (for you nerds, it's about 2+ pitting edema) and it's still hurting him. poor fella.

Hope that all gets resolved soon.

4. Anyway friends, I don't like any of you, not even a little bit, and I'm certainly not excited to see you all very soon. Nope, not excited at all.

P.S. Figure out which one is the lie.

thumbs down...

The thing that I do like about Internal Medicine, or Family Practice, is that I get to see the end of the story, instead of being left with endless cliffhangers like in the ER.

It was always like I got to watch half of a movie, and just when it was getting good, just when I was hooked, some jerk turned off the TV... or the sattelite cut out, or the DVD was scratched beyond repair. I once actually had lightning strike right outside the door of my place where I was watching a movie, not 20 feet away. It fried the VHS right in the VCR. (yea, it was in the VHS days.) That was a serious let down... what happened to the protagonist? did he get the girl? did he achieve his seemingly impossible dream? did he survive the barrage at Bastogne? who knows..... and now that the tape's fried, you're not gunna.

well, that's how it often was in the ER. we could often figure things out, stabilize and such. but even with a diagnosis, there was often further workup and treatment. I never knew what happened to these folks. Did the guy with the AAA we found make it through surgery? Did the lady in DKA ever get out of the ICU? well, who knows... so pop in another movie... 37 yowm, overdose, just barely breathing...... wonder how this one will end. however it ends, i'll never know.

But in the clinic, I get to see page one to page done. well, at least for certain things. Diabetes isn't ever going to just end... COPD... these things go on, but there are tenable endpoints and concrete answers to certain questions here.

Take for example my 31 year old male who came in a few days ago for leg pain. He had run home from work a few days ago, and woke up the next morning with what he said felt like a pulled groin. So he'd been trying to take it easy, but still had been going to work where he's on his feet all day. So now his calf and part of his hamstring were bothering him. He figured he'd been sort of compensating for his hurt groin... walking differently, using different muscle groups.

Well, this sounded about right to me. His history sure made sense for this, and his physical was pretty normal, his calf was awfully tender to palpation though... awfully tender. and is that R calf looking a bit larger than the L? hmmm.

I go back and talk to my preceptor, who's an awfully good PA, and told her what I found on HX and PE. I told her what I thought it was, most likely, and what I wanted to do. (On a sort of side note, she asked me what I thought about Homan's sign, and I said it was bogus... that it had a low specificity and sensitivity, so I didn't do it. Thank you Prof. Randolph.)

So we go back in there and tell him that we are going to give him something for the pain, that it's most likely a musculoskeletal injury like he thought. We went on to tell him that to be on the safe side, we wanted to send him for a right leg ultrosound to rule out a DVT.

Tick, tock.... tick, tock.

A few more minutes pass in the movie.... our protagonist is off to battle.

A few more minutes elapse on the DVD.... (2 days pass) and our hero returns.... I see him limping through the waiting area. It seems his wounds aren't yet healed.

He arrives to the nurses station, looks over at me, and after a smile and "Hey!" from me, he smiles back, but gives me a double thumbs down as he shakes his head.

I already know what has happened.

"Not good news, huh..." I sigh.

"Nope." he replies, with a sort of sad smile.

"I'll be in to talk to you in a minute."

It turns out that our friend did actually have a popliteal DVT. Which explains the extreme tenderness to palpation of his calf, worse as you neared the popliteal fossa. It also explains why his right calf appeared a bit more swollen than his left.

He had already been started on Lovenox the day prior, right when he got the diagnosis (an anti-coagulant for you non-geeks.) and he was here for another round of shots, 80 mg subQ of Lovenox. We also started him on Coumadin (another anti-coagulant, but one you can take in pill form.) so we could get him off the heparin in a week or so, once the Coumadin was in its therapeudic range.

He's only 31 years old, a 5 pack year smoking history, (a kind of wimpy smoking history). NO other risk factors for DVT. This meant that our movie is not quite near the end.

We needed to do some more looking.... this meant bloodwork for things that could cause a hypercoagulable state, one of the most likely being a coagulation cascade factor mutation called Factor V Leiden. So we got more blood from him, sent it off to lab, and sent him home.

The story will continue tomorrow.

Lets pray this isn't a 'Lord of the Rings' trilogy... Let's pray it's a shorter movie... shorter is better for this hero. Lets pray that this movie ends with a Factor V problem, he can live with this. If everything comes back clean, and the movie gets longer, it's because we need to go cancer hunting... I don't want to go cancer hunting.

I'm in the mood for a good thriller of a movie, some mystery, some suspense... but I'm a sucker for a happy ending. I live for the happy ending.

I'll let you know if this has a happy ending. But at least I get to see the rest of this movie, because I'm hooked.

*the previous story is HIPAA compliant. names have been excluded, dates, sexes, ages and such have been changed to protect the innocent. (and they always will be on this blog.)*